Reflection in medical education: intellectual humility,discovery, and know-how

Medicine, Health Care and Philosophy - Reflection has been proclaimed as a means to help physicians deal with medicine’s inherent complexity and remedy many of the shortcomings of medical...     

Temporal characteristics of decisions in hospital encounters: A threshold for shared decision making? A qualitative study

Objective

To identify and characterize physicians’ statements that contained evidence of clinically relevant decisions in encounters with patients in different hospital settings.

Methods

Qualitative analysis of 50 videotaped encounters from wards, the emergency room (ER) and outpatient clinics in a department of internal medicine at a Norwegian university hospital.

Results

Clinical decisions could be grouped in a temporal order: decisions which had already been made, and were brought into the encounter by the physician (preformed decisions), decisions made in the present (here-and-now decisions), and decisions prescribing future actions given a certain course of events (conditional decisions). Preformed decisions were a hallmark in the ward and conditional decisions a main feature of ER encounters.

Conclusion

Clinical decisions related to a patient–physician encounter spanned a time frame exceeding the duration of the encounter. While a distribution of decisions over time and space fosters sharing and dilution of responsibility between providers, it makes the decision making process hard to access for patients.

Practice implications

In order to plan when and how to involve patients in decisions, physicians need increased awareness of when clinical decisions are made, who usually makes them, and who should make them.     

Bone mass in patients with rheumatoid arthritis

Bone loss was evaluated in 118 patients with rheumatoid arthritis by measurement of the total width and marrow cavity of the second metacarpal bone. Both in men and women a significant increase in width of the medullary cavity could be demonstrated, probably due to bone loss at the endosteal surface. Although a certain increase in the total width of the second metacarpal bone took place in men but not in women, combined cortical thickness and metacarpal bone mass decreased significantly. There was no significant difference in the values in patients on gold treatment and in patients without systemic treatment, while patients treated with steroids demonstrated a significantly greater loss of endosteal bone compared to the other two groups. Some correlation was found between the severity of joint involvement and the measured loss of cortical bone. In summary, the study shows that bone loss takes place in patients with rheumatoid arthritis, being most pronounced in steroid-treated patients, in postmenopausal women, and in patients with more severe joint involvement.     

Prevalence of Epilepsy and Epileptic Seizures in 10-Year-Old Children: Results from the Metropolitan Atlanta Developmental Disabilities Study

Summary: With reported prevalence rates of 4–9 cases per 1,000 children, childhood epilepsy is a major public health concern. Reported prevalence rates vary, mainly because researchers often use different epilepsy definitions. In addition, total prevalence may be underestimated if incomplete case-ascertainment methods are used. We used a multiple-source case-ascertainment method that included obtaining information from electro-encephalogram laboratories to estimate the prevalence of epilepsy and to classify seizure types among 10–year-old children. In the metropolitan Atlanta (GA, U.S.A.) area, we found a lifetime prevalence of childhood epilepsy of 6 per 1,000 (95% confidence interval, 5. 5–6. 5) 10-year-old children. However, using capture-recapture analysis, this prevalence may be as high as 7. 7 per 1,000. Proportionately more boys than girls had epilepsy. The prevalence did not vary appreciably by race. Partial seizures, including secondarily generalized seizures, were the most common seizure type (58%). Of children with epilepsy, 35% had another developmental disability (mental retardation, cerebral palsy, visual impairment, or hearing impairment). An accurate estimate of the public health burden of childhood epilepsy and determination of possible risk factors for idiopathic epilepsy both depend on conducting complete community-based case ascertainment and obtaining detailed clinical data.     

Self-monitoring dietary intake: current and future practices.

This article reviews the literature on the use of paper diaries for self-monitoring food intake, identifies the strengths and limitations of paper-and-pencil diaries and their new counterpart, the electronic diary or personal digital assistant (PDA), and reports how participants were trained to use a PDA with dietary software in two pilot studies--one with hemodialysis patients and the other with participants in a weight loss study. The report of the pilot studies focuses on the practical issues encountered in training participants in the use of a PDA and addresses the pros and cons of different dietary software programs. Six hemodialysis patients were trained in the first study and seven participants attempting to lose or maintain their weight were trained in the second pilot study. The training focused on how to use a PDA and how to navigate the dietary software to self-monitor food intake. The goals of using the PDA were to improve adherence to the therapeutic diets and to self-monitoring. Lessons learned from the pilot studies are shared.     

Improvement of hand dexterity induced by stimulation of the peduncolopontine nucleus in a patient with advanced Parkinson’s disease and previous long-lasting bilateral subthalamic DBS

We report the case of a patient already submitted to bilateral deep-brain stimulation (DBS) of the subthalamic nucleus (STN) who started to develop gait impairment, postural imbalance and frequent falls in the course of the disease and who subsequently underwent DBS of the right pedunculopontine nucleus (PPN) at our institute. An immediate clinical benefit in hand dexterity was observed with acute external stimulation and maintained after the definitive implant of the internal pulse generator (IPG) at 6 months’ follow-up. The benefit on hand dexterity seemed to be related to the interactions between the PPN low-frequency stimulation and the bilateral STN high-frequency stimulation.     

Pneumonia due to Candida krusei

A case of post-transplantation pneumonia due to Candida krusei is reported. A 42-year-old man was admitted 28 days after heart transplantation with cough, pleuritic pain and fever. A chest computed tomograph showed multiple alveolar infiltrates bilaterally. He received broad-spectrum antibiotics, fluconazole for oral candidiasis, and cotrimoxazole for possible Pneumocystis carinii . A short-lived period of improvement was followed by respiratory failure. Cultures of bronchial washings grew C. krusei and C. albicans . The infection was documented by histology and culture obtained by transthoracic aspiration. Treatment with amphotericin B was initiated, but the patient died. Histology and culture of a pulmonary specimen, obtained immediately post mortem, further documented the infection with C. krusei .